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ERISA Claim Denials


Guest Hobknob
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Guest Hobknob

When a medical claim is initially denied, ERISA requires that the claimant be informed, among other things, of the specific reason for the denial and that reference be made to the specific plan provisions. Does this mean a claimant must be informed to look, for example, at a specific page and heading of a plan booklet, or would it suffice to simply inform the claimant to review the general limitations and exclusions as set forth in the plan?

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If you are denying a claim that has been filed with the plan (as opposed to a normal EOB), I recommend you hire ERISA counsel because once a claim has reached that point, as the case law reads, you are in litigation already.

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